INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 17, 2014 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, James A. Casey House, LLC. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observation, the facility failed to ensure privacy so that counseling sessions could not be seen outside the counseling room in one of two group counseling rooms inspected. The findings include:During the inspection, the Licensing Specialist utilized a group counseling room located towards the rear of the building. It was observed that the door exiting to outside of the facility lacked any window treatments. Thus, enabling a person standing outside at ground level to view group counseling sessions.The Project Owner and Project Director did not dispute the findings.
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Plan of Correction
A blind has been placed over the window preventing anyone from seeing inside the counseling area. The Building Maintenance Director will be responsible for ensuring that all counseling areas meet the appropriate standards. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations in four of nine client records reviewed.The findings include:Nine client records requiring documentation of physical examinations were reviewed on January 17, 2014. The facility failed to complete physical examinations as part of the intake process in client records #1, 3, 6, and 9.Client #1 was admitted on January 8, 2014 and was still an active client as of the date of the on-site inspection. The intake process was completed on January 8,2014, but there was no physical examination documented in the client record as of the date of this inspection.Client #3 was admitted on December 2, 2013 and was still an active client as of the date of the on-site inspection. The intake process was completed on December 2, 2014, but there was no physical examination documented in the client record as of the date of this inspection.Client #6 was admitted on December 6, 2013 and was discharged on January 16, 2014. The intake process was completed on December 6, 2014, but there was no physical examination documented in the client record as of the date of this inspection.Client #9 was admitted on October 21, 2013 and was discharged on December 3, 2013. The intake process was completed on October 21, 2013, but there was no physical examination documented in the client record as of the date of this inspection.The Project Owner and Project Director did not dispute the findings.
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Plan of Correction
Client #1 received a physical on 1/24/14. Client #3 was discharged from the program on 1/28/14 and did not receive a physical exam. Clients #6 and #9 were discharge before licensing inspection and could not be scheduled for a physical exam.
At intake, the client's counselor will schedule a physical exam, for all clients who have not received one from their referral source, for within the first week of treatment. During the first treatment plan review (one month after intake) the Clinical Director will be responsible for ensuring that all clients have a physical exam.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in two of nine client records reviewed.The findings include:Nine client records requiring documentation of a preliminary treatment and rehabilitation plan were reviewed on January 17, 2014. The facility failed to document preliminary treatment and rehabilitation plans in client records #1, and 2.Client #1 was admitted on January 8, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.Client #2 was admitted on January 2, 2014 and was still an active client as of the date of the on-site inspection. There was no preliminary treatment and rehabilitation plan documented in the client record as of the date of the inspection.The Project Owner and Project Director did not dispute the findings.
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Plan of Correction
Preliminary treatment plans have been completed for clients #1 and #2. Preliminary treatment plans will be completed for all clients within the first three days after intake. During case consultation reviews the Clinical Director will be responsible for ensuring that all clients have a preliminary treatment plan. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record on an individual, which includes information relative to the client's involvement with the project in four of nine client records reviewed.The findings include:Nine client records requiring a complete client record on an individual were reviewed on January 17, 2014. The facility did not provide a complete client record for client #s 1, 5, 8, and 9.Client #1 was admitted 1-8-14 and was still active at the time of the on-site inspection. The facility failed to include documentation of a Record of Service in the client record. In addition, the facility failed to include documentation of any of the client's group progress notes.Client #5 was admitted 10-25-13 and was still active at the time of the on-site inspection. The facility failed to include documentation of any of the client's group progress notes.Client #8 was admitted 11-6-13 and was discharged on 12-4-13. A follow up was to be completed no later than January 4, 2014; however there was no follow up documented as of January 17, 2014.Client #9 was admitted 10-21-13 and was discharged on 12-3-13. A follow up was to be completed no later than January 3, 2014; however there was no follow up documented as of January 17, 2014.The Project Owner and Project Director did not dispute the findings.
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Plan of Correction
A Record of Service has been placed in client #1's folder. Client's group progress notes have been placed in the folders of client's #1 and #5. Client follow-ups will be completed for all clients who successfully complete our program. During case consultation reviews the Clinical Director will be responsible for ensuring that all client records contain all the necessary forms and documentation. |